Should health professionals be anonymous or non-anonymous online?

This is a topic I’ve been thinking about for quite some time. Today, the General Medical Council announced that doctors should identify themselves on social media. To the best of my knowledge my own regulator, the Nursing and Midwifery Council, has not yet issued a similar rule. However, I wonder if this is an indicator of what other professions are also likely to do.

Professionals blog and tweet under pseudonyms for all kinds of reasons, and by no means all of these reasons are ominous. Ermintrude2 and Dr Grumble not only use their platforms appropriately and ethically; they also write extremely well and passionately. Some people just feel more comfortable under a pseudonym, and feel more able to speak frankly.

I’ve been Zarathustra on various blogs, and more recently on Twitter, over the years. I’ve grown quite fond of and attached to my online alter ego. Look at Zarathustra’s awesome moustache! I can’t actually grow a moustache in real life. Despite being a grown man any attempts turn into something resembling teenage bumfluff. I ask you, who wouldn’t want a tache like Zarathustra’s?

Over the years I’ve noticed attitudes to social media and healthcare steadily evolving. At first it was something of a free-for-all. I remember the anarchic days of NHS Blog Doctor, Dr Rant and Militant Medical Nurse. A lot of those early blogs were expletive-fuelled swearathons, with people yelling all kinds of earthy insults at NHS managers, at politicians and frequently each other. The language was of a variety that would have a fishwife telling people to tone it down a bit.

A lot of those blogs simply aren’t there any more. In some cases, I suspect it’s because people got into trouble. Some people found out the hard way that internet anonymity can be seriously overrated, especially in the long run. As behaviour on social media started to find its way into disciplinary hearings and fitness-for-practice investigations, the professional guidance became more detailed and suddenly everyone became incredibly anxious about social media. It became a demonic creature, waving a P45 in one hand and a letter from the NMC in the other.

That anxiety is still around, but I’ve also noticed a more mature set of thinking around social media starting to emerge. The Royal College of GPs’ Social Media Highway Code, and Victoria Betton and Victoria Tomlinson’s Social Media in Mental Health Practice give good examples of this new maturity. What these publications say is, remember your responsibilities to behave ethically, but also maintain a sense of playfulness to explore this evolving medium, and work out how it can be used as a force for good.

And there’s no doubt that social media can be a force for good. Last night I joined in the #mhnursechat on Twitter, which was on the subject of borderline personality disorder. This is a difficult topic, often laden with mutual suspicion on both sides. Patients with this condition are often regarded as “difficult” or “attention-seeking”. Professionals are accused of dismissing the suffering of people with BPD, and using it as a label to stigmatise and exclude rather than provide support.

The chat was joined not only by mental health nurses but also by a number of people with BPD. For an hour everybody talked openly, equally and respectfully. We talked about what the diagnosis means to people, what helps and what doesn’t help. The feedback from participants at the end spoke for itself.

“brilliant to be able to collaborate with mutual respect for each other, a wonderful experience”

“It was such a nice change to be included instead of being ignored and spoken over so to speak”

“brilliant to see and I am glad that patients welcomed in #mhnursechat not just professionals”

“What a brilliant & informative chat. Thank you all so much for joining in”

Social media, by its nature, puts together people who would never have met. It creates strong public voices which didn’t get there through traditional routes. It creates stories that appear from odd angles and at unexpected times. It makes public issues of things that might once have remained behind closed doors. It doesn’t let things stay where policy makers have traditionally put them.

It also creates a situation for mental health where it is less ‘them and us’ and more ‘just us’. There is something hugely satisfying in seeing someone who offline would be seen as a ‘patient’ discussing online with someone who would be seen as an ‘expert’ and both learning from that experience.

Returning to the question of whether to blog and tweet anonymously or non-anonymously, there is the matter of accountability in all this. Ironically my recent Twitter run-in with Dr Christian Jessen has galvanised my thinking on this matter. I’ve been criticised for “calling out” Dr Jessen on his online statements. Personally I don’t think I’ve done anything wrong in that regard. I think he behaved disgracefully in an extremely public manner, and that I’m entitled to criticise that behaviour. But should I be hiding behind an anonymous ID to do so? If I’m confident in what I’m saying, shouldn’t I be willing to put my name to it, and if necessary defend it?

As well as being accountable, there’s also the matter of taking credit for what you’ve done well. There are pitfalls in social media, and if I’m honest with myself I think it’s fair to say I’ve made some mistakes along the way. But there’s also things I’m proud of, such as exposing the shocking lack of regulation in the psychotherapy industry. I’m also proud of helping create and maintain the regular This Week in Mentalists round-ups, in which bloggers take it in turns to tell us about their favourite online mental health writing. I’m proud of the #TwentalHealthAwards that I started this year.

The main reason I blog anonymously is because I sometimes write about real (although anonymised) people and it provides another level of anonymity for them. Telling real stories about my work life is part of the reason why I blog in the first place.
My real identity has become something of an open secret among my local AMHP colleagues, and I have even begun to make personal appearances as The Masked AMHP (without mask). I’ve begun to meet other bloggers in the real world (you know at least one of them, Zarathustra/Philip). It does become tiring to remain anonymous, but I think I will have to keep doing it while I continue to blog about real situations from my work.
However, I have recently been thinking about adopting another nom de plume — how does “The AMHP With No Name” strike you?

It’s your prerogative but you’ve been persuaded to relinquish a vital degree of freedom. A freedom capable of undermining the climate of fear currently pervasive throughout the NHS.

The GMC will by this decision extend the climate of fear, fear of expressing & discussing topics freely (if anonymously) by colleagues. The air resonates with the sound of doors being slammed. Savile would be so relieved.

Now the emphasis will shift away from open discussion & analysis of each topic between those at all levels, to who said what?, who thinks what?, who’s being critical?, who’s awkwardly challenging our hegemony?, shall we exert pressure to ensure they back off?, ah that’s more comfortable!, Mmmm yes it’s such a pity so many died..

Good to know your real name at last! I do understand that people have good reasons for choosing not to use their real names, but wisely or unwisely I do use mine. When I commented on your blog last year under my real name, I got two completely opposite reactions. One was from my husband who was paranoid about lawsuits (which I knew would not happen). Since the further developments he has done a complete 180 and is actively encouraging me to go to the Press with what I know. The second comment was from a close friend of mine who liked what you wrote but said that he felt it a bit suspicious that you did not use your real name.

Woah! Great to meet you! It’s an interesting topic- one that people are still coming to terms with. Ultimately, we’re responsible to our regulators for what we say in social media, as health professionals we’re obliged to offer our registration numbers if asked, so perhaps this will become a norm? Pseudonym and registration number, or real name?

The original form of words in the GMC guidance was very reasonable; but the current form of words applies if you identify as a doctor – i.e. if your bio or any other posts or tweets from the same account identify you as a doctor. Why should doctors be obliged to identify themselves when they are not acting in their professional (work) capacity? Do you not get the reasons why they might, legitimately, choose not to?

I think a lot of professionals feel rather anxious and exposed on social media. Perhaps due to the flurry of guidance in recent years, some people have been left with a sense of “one tweet in the wrong place and you’re up before the regulators.” Hence people may be blogging and tweeting in a perfectly appropriate way, but may feel safer when doing it under a pseudonym.

On the other hand, “coming out” has turned out to be an entirely positive experience for me. It’s been something that I’ve been reflecting on doing for a considerable amount of time, and now I’ve done so I feel liberated rather than exposed.

zomg, I had no idea! To be serious though, you’ve not been all that anonymous for quite a long time really. I think the “no anonymity” will be to give accountability for dr’s and their online presence. it would certainly have gotten rid of that annoying nhs blog dr man much sooner!

Great to see that the topic of anonymity of doctors on Social Media is being discussed. This has been something that my followers on Twitter have seen me ranting on about for some time. On the Monday 25th Australian time, I also uploaded a blog piece on this subject at http://surgicalopinion.blogspot.com.au/2013/03/doctors-on-twitter.html for those who might be interested.

Hi Monica. Glad you have found reality to be liberating. I agree that there are ‘some’ but perhaps not ‘many’ reasons to have anonymity. My belief is that if there is a need for this, then individuals should declare this need to be anonymous in their bio or link. There is nothing wrong with holding a specific account to be anonymous with explanation as well as to hold an unrelated account where their name is revealed. The GMC is not taking away a right for anybody to be anonymous – it is a case of where if a doctor wants to declare that they are as such, then they ‘should’ use their real name. On another note, I have seen a number of cases just recently where ‘anonymous doctors’ have been giving personal advice on ultrasound results (without having taken a history or seen any images at all) or making denigrating comments about cancer care (thinking it a big joke) – it only takes a small number of irresponsible doctors (and sadly there are a number of these) which drive regulators in the direction of lowest common denominator rules.

I was talking more generally about the need for anonymity…not among professionals so much specifically…but more like generally among members of oppressed groups etc. It’s not always safe to be out and some people have damn important things to share from that place…some of them may also be professionals.

sorry for the multiple messages here…I thought I should be clear…I totally agree that anonymity is often abused in many ways…I’m not arguing against that at all. Thanks very much for the discussion. I think it’s a very important one.

Yes, agree it’s fine & much better to use SM in own name if brave or just confident or one of top brass or merely uncontroversial or non-confrontational.

However, the confidential degree of freedom snatched by the GMC is vital – even to begin any long slow reduction in the excessive current climate of fear – just for those not confident, not so brave or not top brass.

For it may be these faltering contributors whose comments, analysis or revelations could otherwise help to save lives, forestall disasters or root out corruption etc.

Institutions aren’t the property of those at the top & they should not be allowed to stride roughshod like colossi – imagining by their height a divine right to speak for the organisation and all its members – over lower mortals with equal and often more acute and representative experiences worth communal evaluation.

It is crucial that those not confident, not so brave or not top brass are nevertheless provided every encouragement to contribute – even if only anonymously initially – rather than condescendingly ‘spoken on behalf of’ by the only-too-visible giants or ridiculed or suppressed or silenced.